FERPA Consent Form
For Release of Records
Under the Family Educational Rights and Privacy Act of 1974, I understand that my educational records
cannot be released or discussed without my permission.
__________________________________________________________________________________________
First Name Last Name Student ID #
__________________________________________________________________________________________
Date of Birth Phone Number
I, therefore, give permission for my educational records to be discussed with or released to the following:
Full Name (Printed) Relationship
Full Name (Printed) Relationship
Information to be released:
This permission to release my records or academic information to the individual or individuals named on
this form applies to (check one):
This specific request only.
This request and any future requests one year from the date of this signed form.
Signature of Student______________________________________________ Date______________________
REVOCATION OF CONSENT (not valid until received by the Records and Registration Office)
I hereby revoke the consent granted above.
Signature of Student_________________________________ Date______________________
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